Jens Greve

Novel pharmacotherapy of acute hereditary angioedema with bradykinin B2-receptor antagonist icatibant.

healthy men. Decreased DHEA-S concentration has been recognized in different chronic diseases (2). In particular, it has been suggested that DHEA-S deficiency is a permanent feature of some autoimmune diseases and may contribute to their aetiology and/or pathophysiolgy (4, 5). However, no direct evidence is available to indicate whether reduced circulating concentration of the hormone contributes to the diseases (2, 5). We do not know whether lower serum concentration of DHEA-S observed in CIU patients is the cause or rather the effect of urticarial processes. It has been suggested that, during inflammatory response, the adrenal steroid production is changed in the direction of cortisol, relative to DHEA and DHEA-S, such hormonal changes being probably necessary to achieve adequate cortisol levels at the expense of adrenal androgens (6). It is interesting to speculate that similar abnormalities in steroidogenesis might occur during chronic urticarial inflammation. How does lower circulating DHEA-S actually contribute to CIU pathophysiolgy? The question proves both, difficult and complex as the specific molecular mechanism of action for DHEA-S, including mechanisms of DHEA-S effect upon the immunological function and inflammation, is unclear (2). In conclusion, on the basis of the present study as well as our earlier investigations, it appears probable that circulating DHEA-S concentration may be lower in CIU patients, regardless of their gender. It seems that declining circulating concentration of DHEA-S is a phenomenon accompanying CIU, yet its significance and underlying mechanisms remain unknown. As adrenal androgens have been reported to exert immunoregulatory effects, it is interesting to speculate on DHEA-S deficiency role in urticarial inflammation irrespective of its primary or just secondary character.

Comparative analysis of resection tools suited for transoral robot-assisted surgery

Introduction of transoral robot-assisted surgery (TORS) has a strong potential to facilitate surgical therapy of head and neck squamous cell cancer (HNSCC) by decreasing the indication for an external surgical approach. However, the availability of resection tools is limited and comparative studies in the context of TORS are not available. In the context of the newest da Vinci Si HD® robotic system, various dissection methods were compared in a surgical animal model using porcine tongue at three different sites representing mucosal, muscular and lymphatic tissue. Resection methods included (a) CO2 laser tube, (b) flexible fiber Tm:YAG laser, (c) monopolar blade, and (d) radio frequency (RF) needle. Specimens were formalin-fixed, paraffin-embedded, cut, and stained with haematoxylin–eosin. Dissected tissue was examined for the width of the incision as well as the individual coagulation zone of each tool at various tissue sites. In addition, instrument costs and performance were determined. The incisions made by the RF needle had the most favourable cutting width and also smaller coagulation defects, as opposed to other tools, granting the best preservation of tumour-adjacent structures and improved pathological assessment. Instrument performance was best evaluated for CO2 laser and RF needle, whereas financial expenses were lowest for RF needle and monopolar blade. Improvement and modification of resection tools for TORS become a relevant criterion in order to facilitate routine usage in the surgical therapy of HNSCC. A consequent decrease in surgical mortality and improved precision of surgical tumour resection could lead to a significant clinical growth potential of TORS.

Effect of C1-Esterase-inhibitor in angiotensin-converting enzyme inhibitor-induced angioedema.

The study objective was to generate pilot data to evaluate the effectiveness and safety of C1‐esterase‐inhibitor concentrate (C1‐INH) compared to standard treatment in patients with angiotensin‐converting enzyme inhibitor (ACEi)‐induced angioedema affecting the upper aerodigestive tract.

Potential Advantages of a Single-Port, Operator-Controlled Flexible Endoscope System for Transoral Surgery of the Larynx

Introduction: Transoral surgery of the larynx is commonly performed with a rigid laryngoscope, a microscope, and a laser. We investigated the potential utility of a flexible, single-port, robot-assisted and physician-controlled endoscopic system to enable easy, transoral surgical access to the larynx. Methods: Transoral laryngeal surgery was performed in human cadavers (n = 4) using the Flex System and compatible flexible instruments. Anatomical landmarks were identified, and mock surgical procedures were performed. Results: Standard laryngeal surgical procedures were completed successfully in a human cadaver model. The built-in HD digital camera enabled high-quality visualization of the larynx. Epiglottectomy, as well as posterior cordectomy, were performed by laser and radio-frequency resection. The flexible design of the compatible tools enabled a nontraumatic approach. Conclusion: The Flex System has the potential to improve surgical access to the larynx, especially in patients with challenging anatomy. The associated flexible instruments enabled completion of surgical procedures in the larynx in a human cadaveric model. Further clinical studies, as well as the development of supplemental technology and tools, are recommended for future clinical applications.

Angioedema induced by cardiovascular drugs: new players join old friends.

During the last years, two new cardiovascular drug classes, namely inhibitors of DPP IV or neprilysin, have been developed. In both cases, there is clinical evidence for their potential to induce angioedema as known already from blockers of the renin–angiotensin–aldosterone system (RAAS). The majority of angioedema induced by DPP IV inhibitors occurs during concomitant treatment with ACEi and is therefore likely mediated by overactivation of bradykinin type 2 receptors (B2). In striking contrast, the molecular pathways causing angioedema induced by neprilysin inhibitors, that is, sacubitril, are unclear, although a contribution of bradykinin appears likely. Nevertheless, there is no clinical evidence suggesting that inhibition of B2 might relieve the symptoms and/or prevent invasive treatment including coniotomy or tracheotomy in angioedema caused by these drugs. Therefore, the risk of angioedema should always be considered, especially in ambulatory care situations where patients have no rapid access to intensive care.

Treatment of angiotensin receptor blocker-induced Angioedema: A case series

Angiotensin II receptor antagonists have been proposed as a replacement therapy after the occurrence of either an angiotensin converting enzyme (ACE) inhibitor‐induced angioedema or cough. However, recent studies indicate that angioedema is associated with elevated bradykinin levels in a small fraction of patients treated with angiotensin‐II‐receptor blockers, suggesting a common pathophysiological mechanism. To date, a standard treatment for angiotensin II receptor blocker‐induced angioedema does not exist.

Recent advances in robot-assisted head and neck surgery.

This article reviews current clinical applications and experimental developments for robotic surgery in the head and neck with special focus on financial challenges, current clinical trials, and the controversial aspect of haptic and tactile feedback.

Prophylaxis in hereditary angioedema (HAE) with C1 inhibitor deficiency.

Hereditary angioedema (HAE) is a rare congenital disorder characterized by recurrent episodes of subcutaneous or submucosal edema. Laryngeal manifestations can be life‐threatening. In the majority of cases, the disease can be adequately treated with an on‐demand approach – in some cases, however, short‐ or long‐term prophylaxis is indicated. Attenuated androgens used to be the drugs of choice, but they are associated with considerable side effects and no longer commercially available in the German‐speaking countries of the EU. They are currently being replaced by more effective and more tolerable agents such C1‐inhibitors, the kallikrein inhibitor ecallantide, and the B2 receptor antagonist icatibant, which have recently obtained market authorization. These new drugs have had a major impact, especially on the indications and procedures for long‐term prophylaxis. According to the most recent international consensus papers and our own experience, self‐administered C1‐inhibitors are now the first option for long‐term prophylactic therapy. The decision for prophylaxis should no longer be based on single parameters such as the frequency of attacks but on adequate overall disease control including quality of life. More drugs are currently being developed, which may lead to further changes in the treatment algorithms of HAE.

Demonstration of nasopharyngeal surgery with a single port operator‐controlled flexible endoscope system

Nasopharyngeal surgery is commonly performed with a rigid endoscope using a transnasal or transoral approach. Here, we demonstrate a flexible single port computer‐assisted endoscopic system enabling easy transoral access to the nasopharynx.

Three different turbinoplasty techniques combined with septoplasty: Prospective randomized trial.

Septal deviation and hypertrophic inferior turbinates are a frequent cause of nasal breathing disorders. The goal of this study was to prove the effectiveness and safety of three current turbinoplasty techniques.